Form Dhcs 5112 - California Initial Certification Application - Health And Human Services Agency Page 9
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11STATE OF CALIFORNIA--HEALTH AND HUMAN SERVICES AGENCY
Department of Health Care Services
Licensing and Certification Branch, MS 2600
PO Box 997413
Sacramento, CA 95899-7413
9.
DOES THE APPLICANT PROVIDE OTHER SERVICES AT THIS LOCATION?
YES
NO
If yes, please identify the type of service(s) provided:
11.
DOES THE APPLICANT HAVE A COUNTY ALCOHOL AND/OR OTHER DRUG PROGRAM CONTRACT?
YES
NO
(If yes, identify funding in annual line-item budget.)
12.
AUTHORIZED SIGNATURE(S) OF APPLICANT:
1.
If the applicant is a sole proprietor, the proprietor shall sign the application.
2.
If the applicant is a partnership, each partner shall sign the application.
3.
If the applicant is a firm, association, corporation, county, city, public agency, or other
governmental entity, the chief executive officer or the individual legally responsible for
representing the firm, association, corporation, county, city, public agency, or other
governmental entity shall sign the application. The application shall include the resolution
or board minutes authorizing the individual to sign.
THE UNDERSIGNED ENSURES THAT THE PROGRAM DOES NOT DISCRIMINATE IN EMPLOYMENT
PRACTICES AND PROVISION OF SERVICES ON THE BASIS OF ETHNIC GROUP IDENTIFICATION,
RELIGION, AGE, SEX, COLOR OR DISABILITY PURSUANT TO TITLE VI OF THE CIVIL RIGHTS ACT OF
1964 (SECTION 2000d, TITLE 42, UNITED STATES CODE); THE AMERICANS WITH DISABILITIES ACT OF
1990 (SECTION 12132, TITLE 42, UNITED STATES CODE); AND FOR RECIPIENTS OF FINANCIAL
ASSISTANCE, THE REHABILITATION ACT OF 1973 (SECTION 794, TITLE 29, UNITED STATES CODE), AND
CHAPTER 6 (COMMENCING WITH SECTION 10800).
THE APPLICANT(S) AFFIRMS THAT THE FACTS CONTAINED IN THIS APPLICATION AND
SUPPORTING DOCUMENTS ARE TRUE AND CORRECT.
(SIGNATURE)
(TITLE)
(DATE)
(SIGNATURE)
(TITLE)
(DATE)
(SIGNATURE)
(TITLE)
(DATE)
Page 9 of 11
DHCS 5112 (07/13)
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